Gastrointestinal Intervention 2017; 6(3): 166-170  https://doi.org/10.18528/gii160031
Percutaneous radiologic gastrostomy in patients with failed percutaneous endoscopic gastrostomy
Tang-fei Lee1, Young Jong Cho2,a, Ji Hoon Shin3,*, Heung Kyu Ko3, Jihong Park3, Soo Hwan Kim3, Jin-Hyoung Kim3, and Ho-Young Song3
1Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, 2Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea, 3Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. E-mail address:jhshin@amc.seoul.kr (J.H. Shin).
Received: October 27, 2016; Revised: April 12, 2017; Accepted: April 12, 2017; Published online: October 31, 2017.
© Society of Gastrointestinal Intervention. All rights reserved.

cc This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background

To determine the technical feasibility and success rate of percutaneous radiologic gastrostomy (PRG) after failure of percutaneous endoscopic gastrostomy (PEG).

Methods

Consecutive patients referred for PRG after failure of PEG between May 2011 and June 2016 were included in this study. The reasons for the failure of PEG, as well as the technical success and complications of PRG were noted.

Results

Fifteen patients (14 men, 1 woman; age, 27–93 years) were included. The most common reasons for PEG failure were esophageal stricture due to malignancies (n = 8), unfavorable abdominal wall conditions (n = 3), unstable patient condition during endoscopy (n = 2), and other miscellaneous conditions (n = 2). PRG placement was technically successful in all 15 cases. In one case, early slip-out of the gastrostomy tube occurred, which required removal and repositioning. No mortality was noted.

Conclusion

PRG is technically feasible in patients with failed PEG insertion, and has advantages over PEG and a high overall success rate.

Keywords: Gastrostomy, Percutaneous endoscopic gastrostomy, Percutaneous radiological gastrostomy
Introduction

Enteral nutrition is considered more advantageous than parenteral nutrition in patients requiring nutritional support.1 Gastrostomy is one of the routes for administering enteral nutrition. The most common indications for gastrostomy include dysphagia secondary to neurological diseases, followed by dysphagia due to head and neck or esophageal malignancies.24 Since the first description of gastrostomy creation through an open approach in 1876,2 minimally invasive alternatives through endoscopic and radiologic approaches were described in 19805 and 1981,6 respectively. Currently, percutaneous endoscopic gastrostomy (PEG) is the first-line approach for gastrostomy creation in many institutions. PEG and percutaneous radiologic gastrostomy (PRG) have similar indications. However, PRG is more advantageous than PEG because it avoids the insertion of a relatively large-bore endoscope orally. In this case series, we reviewed our spectrum of cases to determine the technical feasibility and success rate of PRG after failure of PEG.

Methods

All patients who were referred to the Department of Radiology, Asan Medical Center (Seoul, Korea) from May 2011 to June 2016 for insertion of a PRG tube after failure of PEG were included in this study. The medical records of the included patients were reviewed for primary diagnoses and reasons for PEG failure. Technical details and immediate complications were also reviewed. The study was approved by the Institutional Review Board of Asan Medical Center, and informed consent was obtained from all patients.

Intravenous sedation was initiated with 5 mg/5 mL midazolam under continuous monitoring including blood pressure and oxygen level. Antibiotics (cefotaxime 2 g) and gastroparetic agents (Bropium, cimetropium bromide, 5 mg/mL; Bukwang Pharm., Seoul, Korea) were used. Under fluoroscopic guidance, a Kumpe catheter (5 Fr, 65 cm; Cook, Bloomington, IN, USA) was inserted via the mouth through the esophagus and into the stomach over a hydrophilic guidewire (0.035″, 150 cm, Radifocus; Terumo, Tokyo, Japan). Air was insufflated to distend the stomach until the inflated stomach extended below costal margins and displaced adjacent structures, thereby facilitating gastric puncture. Puncture of the gastric antrum was performed under fluoroscopic guidance using a Chiba needle (21 G, 15 cm; Cook) (Fig. 1). The puncture site was carefully determined and should be lateral to the rectus muscle or in the midline to avoid epigastric vessels. Ultrasound guidance was not routinely used in our series. Contrast was injected to verify the intragastric position of the needle tip. A Neff catheter (6 Fr, 20 cm; Cook) was used in place of a large-bore catheter. Gastropexy was then performed by using Cope anchor (Cook). The one anchor technique was used.7 The tract was serially dilated, and ultimately a 14-Fr gastrostomy tube (Cook) was inserted into the stomach over the guidewire. Contrast was again injected to confirm the position of the gastrostomy tube (Fig. 1). The anchor was then sutured to the abdominal wall, and the gastrostomy tube was fixed to the skin. The tubogram was performed on the next day following the PRG insertion to verify the position and function of the gastrostomy tube. The anchoring sutures were cut one week after the procedure and the anchor was allowed sink into the stomach.

Results

A total of 15 patients were included in this study (14 men, 1 woman). Their ages ranged from 27 to 93 years (mean, 63.7 years). Nine patients had underlying malignancies. Five patients had underlying chronic neurologic conditions. In one case, postoperative infection occurred, leading to vocal cord palsy and necessitating gastrostomy creation.

PRG was successful in all patients (n = 15). In one case, complete obstruction of the esophagus made passing a guidewire through the esophagus impossible. To overcome this situation, direct puncture of the nondistended stomach under ultrasonographic guidance and subsequent air insufflation were performed. After the operator punctured the stomach successfully, contrast was injected to confirm the position of the needle. A micro-guide wire was inserted to exchange for the Neff catheter. The procedure was then continued as in other cases (Fig. 2).

Reasons for failure of PEG

Esophageal stricture was the most common reason for PEG failure, and was observed in all cases of underlying malignancies (n = 8). The tight strictures prohibited the passage of an endoscope into the stomach. In seven of the eight cases, a 5-Fr Kumpe catheter was placed into the stomach with the help of guidewire under fluoroscopic guidance. In the remaining one case, complete occlusion of the upper esophagus was observed. Several attempts were made to puncture the stomach without inflation, finally resulting in a successful puncture.

In three cases, PEG failure was due to unfavorable abdominal wall conditions: failed transillumination due to obscuration by the xiphoid process in one case, thick abdominal wall in one case, and abdominal wall spasm related to spinal cord injury in one case.

In two cases, PEG failure was due to unstable patient condition (desaturation) during endoscopy. The patients in these cases had underlying neurological conditions.

In the remaining cases, PEG failure was due to other conditions, including esophageal erosion and bleeding in one case, and an ambiguous anatomy that the endoscopist deemed unsuitable for PEG in another case.

A summary of patient demographics and reasons for PEG failure is given in Table 1.

Complications

In one case, migration of the gastrostomy tube into the peritoneal cavity occurred, which was discovered on a routine tubogram performed on day 1 after the procedure (Fig. 3). The gastrostomy tube was removed, and PRG was performed again uneventfully. No other major complications were encountered.

Discussion

Our study showed that PRG is a feasible alternative for patients with failed endoscopic gastrostomy.

Previous studies have demonstrated a high technical success rate of PRG in patients with advanced esophageal cancer, which may preclude placement of an endoscopic gastrostomy tube.8,9 PRG has the obvious advantage of being able to bypass any upper aerodigestive tract obstruction. In addition, the presence of an esophageal stricture may increase the risk of perforation and bleeding in patients with such obstructions.10 Furthermore, although considered very rare, metastatic deposits from head and neck squamous cell carcinoma may occur at the gastrostomy site.2,3,10,11

Cardiorespiratory compromise is not uncommon in upper gastrointestinal endoscopy.10 This can be related to sedation or the procedure itself, and this problem can be overcome with PRG. The insertion of a small-bore PRG tube seems much easier than large-bore PEG although tube clogging is more common in small-bore PRG. In our series, PRG was performed without sedation, therefore eliminating the risks of sedation.

One of the major concerns about PRG is the possibility of injuring adjacent organs. Distending the stomach by means of gas insufflation can effectively displace adjacent structures and guide fluoroscopic puncture. Ultrasound or computed tomography guidance has also been proposed.1215 Alternatively, inadvertent puncture of the colon can be avoided by asking the patient to ingest barium on the day before the procedure in order to opacify the colon. In some cases, the obstruction in the esophagus can be so severe that passing a guidewire or a small feeding tube through the obstruction is impossible. Without air insufflation, the stomach can be difficult to locate. However, PRG is still possible in such cases.16 In our experience, even without distending the stomach, accurate puncture of the stomach is still possible under ultrasonography. By injecting small amount of contrast medium through the puncture needle, we also can confirm the needle position in fluoroscopic manner.

In our series, there was one case of PEG failure due to rigidity of the abdominal wall in a patient with quadriplegia due to spinal cord injury. A rigid abdominal wall is difficult to indent when identifying the puncture site for gastrostomy by using an endoscope, and we found that PRG can overcome this difficulty.

In one case, early slip-out of the gastrostomy tube occurred. This was not an intraprocedural misplacement because we routinely inject contrast to confirm the tube position immediately after placement. The early slip-out of the gastrostomy tube may be related to a suboptimal opposition between the gastric wall and the anterior abdominal wall. The anchor stitch may loosen after the procedure, and operators should be aware of this possibility when handling the anchor. Although this complication may be prevented by placing more anchors, previous studies have shown that the one-anchor technique is adequate.7,1719

In conclusion, our series shows that PRG can be successfully performed with a relatively low incidence of adverse events for patients with failed PEG. PRG should be actively considered for these patients. In fact, better patient selection may help avoid performing a relatively invasive but unsuccessful PEG procedure in some patients, with a probable added advantage of reduced medical costs.20

Figures
Fig. 1. Percutaneous radiologic gastrostomy in patient with esophageal stricture. (A, B) Stomach is insufflated by air via 5 Fr Kumpe catheter (arrowheads; Cook, USA). A 21 G Chiba needle (arrows; Cook) is used to puncture under fluoroscopic guidance. Small amount of contrasts are injected to verify the position of needle. (C, D) A Neff catheter (arrowheads; Cook) is advanced over the micro-guide wire (arrows). (E) The anchor (arrowheads) is deployed by the guide wire (arrows) and by traction of the anchor, the anterior stomach wall is opposed to abdominal wall. (F) The tract site is serially dilated and a 14 Fr gastrostomy tube is placed. Small amount of contrast is injected through the gastrostomy tube (arrows) to verify final intra-gastric position of the tube.
Fig. 2. Placing a gastrostomy tube in patient with nondistended stomach due to complete esophageal obstruction. (A) Passing a guidewire (arrows) through the stricture is impossible. (B) A Chiba needle (arrows; Cook, USA) is used to puncture the nondilated stomach under ultrasonographic guidance (not shown). Contrast is injected through the Chiba needle, and the image shows the spread of contrast medium in the nondistended stomach. (C) Insertion of a 0.018″ microguidewire (arrows) via the Chiba needle (arrowheads) into the stomach. (D) Insertion of a 6-Fr Neff catheter (arrows) over the microguidewire. The stomach is air-inflated through the Neff catheter (Cook). (E) The anchor (arrowheads) is pushed with a 0.035″ guidewire (arrow) through the Neff catheter. The Neff catheter is subsequently removed. (F) Gastrostomy catheter is successfully inserted after serial dilation of the tract.
Fig. 3. (A) Post-procedural tubogram on day 1 showing contrast spillage into the peritoneal cavity, indicating peritoneal displacement of the gastrostomy tube. The anchor (arrow) seems to be displaced outside the stomach. (B) The shadow of the tip of scissors indicates the puncture site. The anchor (arrow) seems displaced from the puncture site. The tube was promptly removed and the gastrostomy tube was reinserted 1 week later without complications.
Tables

Table 1

Summary of Patient Demographics and Reasons for PEG Failure

Patient no.Age (yr)/sexDiagnosisReasons for PEG failure
146/FThyroid cancerEsophageal stricture
227/MQuadriplegiaAbdominal wall muscle spasm
356/MMotor neuron diseaseUnstable patient condition during endoscopy
465/MEsophagus cancerEsophageal stricture
570/MLung cancerEsophageal stricture
674/MEsophagus cancerEsophageal stricture
793/MAlzheimer’s diseaseUnstable patient condition during endoscopy
870/MParkinsonismEsophageal erosion
980/MParkinsonismFailed endoscopic puncture owing to a thick abdominal wall
1062/MHypopharynx cancerEsophageal stricture
1174/MVocal cord palsyDistorted gastric anatomy
1272/MLung cancerFailed transillumination
1340/MThyroid cancerEsophageal stricture
1461/MEsophagus cancerEsophageal stricture
1565/MEsophagus cancerEsophageal stricture

PEG, percutaneous endoscopic gastrostomy; F, female; M, male.

References
  1. Seres, DS, Valcarcel, M, and Guillaume, A (2013). Advantages of enteral nutrition over parenteral nutrition. Therap Adv Gastroenterol. 6, 157-67.
    Pubmed KoreaMed CrossRef
  2. Lyon, SM, and Pascoe, DM (2004). Percutaneous gastrostomy and gastrojejunostomy. Semin Intervent Radiol. 21, 181-9.
    Pubmed KoreaMed CrossRef
  3. Rahnemai-Azar, AA, Rahnemaiazar, AA, Naghshizadian, R, Kurtz, A, and Farkas, DT (2014). Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 20, 7739-51.
    Pubmed KoreaMed CrossRef
  4. Shin, JH, and Park, AW (2010). Updates on percutaneous radiologic gastrostomy/gastrojejunostomy and jejunostomy. Gut Liver. 4, S25-31.
    Pubmed KoreaMed CrossRef
  5. Gauderer, MW, Ponsky, JL, and Izant, RJ (1980). Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 15, 872-5.
    Pubmed CrossRef
  6. Preshaw, RM (1981). A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet. 152, 658-60.
    Pubmed
  7. Kim, JW, Song, HY, Kim, KR, Shin, JH, and Choi, EK (2008). The one-anchor technique of gastropexy for percutaneous radiologic gastrostomy: results of 248 consecutive procedures. J Vasc Interv Radiol. 19, 1048-53.
    Pubmed CrossRef
  8. Sofue, K, Takeuchi, Y, Tsurusaki, M, Shibamoto, K, Sakamoto, N, and Kitajima, K (2016). Value of percutaneous radiologic gastrostomy for patients with advanced esophageal cancer. Ann Surg Oncol. 23, 3623-31.
    Pubmed CrossRef
  9. Thornton, FJ, Varghese, JC, Haslam, PJ, McGrath, FP, Keeling, F, and Lee, MJ (2000). Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy. Cardiovasc Intervent Radiol. 23, 279-84.
    Pubmed CrossRef
  10. Ben-Menachem, T, Decker, GA, Early, DS, Evans, J, Fanelli, RD, and ASGE Standards of Practice Committee (2012). Adverse events of upper GI endoscopy. Gastrointest Endosc. 76, 707-18.
    Pubmed CrossRef
  11. Huang, AT, Georgolios, A, Espino, S, Kaplan, B, Neifeld, J, and Reiter, ER (2013). Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: case series and literature review. J Otolaryngol Head Neck Surg. 42, 20.
    Pubmed KoreaMed CrossRef
  12. Wu, TS, Leech, SJ, Rosenberg, M, Huggins, C, and Papa, L (2009). Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube placement at the bedside. J Emerg Med. 36, 280-4.
    CrossRef
  13. Lorentzen, T, Skjoldbye, B, Nolsøe, C, Torp-Pedersen, S, and Mygind, T (1995). Percutaneous gastrostomy guided by ultrasound and fluoroscopy. Acta Radiol. 36, 159-62.
    Pubmed CrossRef
  14. de Bucourt, M, Collettini, F, Althoff, C, Streitparth, F, Greupner, J, and Hamm, B (2012). CT fluoroscopy-guided percutaneous gastrostomy with loop gastropexy and peel-away sheath trocar technique in 31 amyotrophic lateral sclerosis patients. Acta Radiol. 53, 285-91.
    Pubmed CrossRef
  15. Covarrubias, DA, O’Connor, OJ, McDermott, S, and Arellano, RS (2013). Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. AJR Am J Roentgenol. 200, 921-31.
    Pubmed CrossRef
  16. Chan, SC, Chu, WC, Liu, KW, Liao, CT, Lee, TS, and Ng, SH (2011). Modified radiology-guided percutaneous gastrostomy (MRPG) for patients with complete obstruction of the upper digestive tract and who are without endoscopic or nasogastric access. Korean J Radiol. 12, 216-9.
    Pubmed KoreaMed CrossRef
  17. Shin, JH, Song, HY, Kim, TH, Kim, KR, Choi, KE, and Kim, JH (2010). Percutaneous radiologic gastrostomy: a modified Chiba-needle puncture technique with single gastropexy. Abdom Imaging. 35, 189-94.
    CrossRef
  18. Jeong, EJ, Song, HY, Park, JH, Shin, JH, Kim, JH, and Kim, SH (2015). Preliminary results of percutaneous radiologic gastrostomy in a pediatric population: a modified chiba-needle puncture technique with single gastropexy. AJR Am J Roentgenol. 205, W133-7.
    Pubmed CrossRef
  19. Park, JH, Shin, JH, Ko, HK, Kim, JH, Song, HY, and Kim, SH (2014). Percutaneous radiologic gastrostomy using the one-anchor technique in patients after partial gastrectomy. Korean J Radiol. 15, 488-93.
    Pubmed KoreaMed CrossRef
  20. Galaski, A, Peng, WW, Ellis, M, Darling, P, Common, A, and Tucker, E (2009). Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol. 23, 109-14.
    Pubmed KoreaMed CrossRef


This Article


Cited By Articles
  • CrossRef (0)

Services
Social Network Service

e-submission

Archives